Registration | Honolulu Judo Club

Membership Registration Form

Today's Date

Member Information:

First Name

Last Name

Date of Birth

Age

Sex

Male

Female

Address

Primary Phone Number

If Member is a Minor:

Father/Guardian First Name

Father/Guardian Last Name

Father/Guardian's Email

Father/Guardian's Phone Number

Mother/Guardian First Name

Mother/Guardian Last Name

Mother/Guardian's Email

Mother/Guardian's Phone Number

Medical Issues/Physical Limitations:

Medical or physical problems that the instructor should be aware of

Emergency Contact Information (if different from above):

Emergency Contact

Relationship

Emergency Contact's Phone Number

Previous Judo Experience:

Dojo/Sensei

Current Rank

How did you hear about HJC?

Internet

Member

Other

Years Experience

Why are you interested in taking judo at HJC?

Billing:

Send monthly invoice to

My email

Father/Guardian's email

Mother/Guardian's email

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